Enterocutaneous fistula

Background

• Abnormal connection from the gastrointestinal tract to the skin

Etiologies

• Surgical complications
• Diverticular disease
• Crohn disease
• Malignancy
• Radiation
• Infection, particularly with perianal fistulas
  • Includes tuberculosis and actinomycosis

Risk Factors for Persistence

• Mnemonic is HIS FRIEND
• High output
• Inflammatory bowel disease
• Short tract (<2 cm)
• Foreign body
• Radiation
• Infection or inflammation
• Epithelialization
• Neoplasm
• Distal obstruction

Classification

• May be classified by output:
  • High output: >500 mL/24 hours
  • Moderate output: 200 to 500 mL/24 hours
  • Low output: <200 mL/24 hours
• May be classified by etiology:
  • Iatrogenic: operations for malignancy, adhesiolysis, IBD, and trauma, mostly from anastomotic leaks
  • Spontaneous: IBD, malignancy, appendicitis, diverticulitis, radiation, tuberculosis, actinomycosis, ischemia
• Maybe classified by GI source:
  • Type I: abdominal, esophageal, and gastroduodenal
  • Type II: small bowel
  • Type III: large bowel
  • Type IV: enteroatmospheric, regardless of origin

Management

• Needs multidisciplinary care to optimize nutrition, assess fistulous tract anatomy, provide good wound care, and manage the underlying disease
• Nutrition and fluid maintenance is important, especially for high-output fistulas
• When they develop infections:
  • Percutaneous drainage of any abscesses
  • Antibiotics should cover GI pathogens
  • In general, antibiotics are not needed beyond source control
  • Duration of about 4 to 7 days is typically enough

Further Reading

• Enterocutaneous Fistula: Proven Strategies and Updates. Clin Colon Rectal Surg. 2016 Jun; 29(2): 130–137. doi: 10.1055/s-0036-1580732